Sleeplessness

SIR: Patients with eating disorders commonly employa varietyof strategiestocontroltheirweight whichmayleadto harmfulphysicalconsequences â€”¿ thedesirefor weightlossoverridingconcernsabout physicalwell-being.Patientsmay compromisethe careof coexistingmedicalillnessesuchasdiabetes and Crohn's diseasein order to lose weight (Treasure, 1991). We have recently seen a young womanwhodescribedtryingto contractSalmonella typhiasa meansof weightcontrol.


She gave a three-yearhistoryof daily binges on large quantities of high-calorie carbohydrate foods and of self
inducedvomitingtwicedaily. Her overconcern with her weight led her to walk 4â€"5 miles a day, swim four times a week and exerciseat home â€oe¿ until the point of painâ€•. She had ahistory ofabuse oflaxatives andappetite suppressants.
Ms A decidedto try to contractSalmonella typhiafter hearingacolleagueat workdescribe howhehadlosta stone in weightfollowingSalmonella foodpoisoning. To try to contract the infection she ate partially defrosted raw chicken,mixingit with curry powderto renderit more palatable. Sheleft outsausages for oneweekbeforeeating them and on two occasions ate reheated pork as she believedthatthiswasparticularly likelyto leadto infection.
DespitehereffortsMs A remained freeof anysickness and diarrhoea. She has now stopped trying to make herself unwell but does admit to fantasising about being involved in a road trafficaccident. Sheimagines beingâ€oe¿ in a coma unableto eat and on a dripâ€•, as she feelsthis wouldlead to substantial weightloss. Becauseof the secretivenature of weight control strategies we were unable to corroborate this patient's reported behaviour, although she had given a similarhistoryto her GP. Unlike thosepatientswith Munchausen's syndrome (Asher, 1951) who present with artefactual illness, our patient sought genuine physical illness as she welcomedthe symptoms of anorexia and weightloss.
We are not aware of any other reports of eating dis order patients trying to contract food poisoningand we would beinterestedto hear of any other cases. We suggest that it might be politic to name this behaviour Currie's complaint in honour of the member from Derbyshire South. methods, even such occasionally useful aid. This attitude is but rational, if we consider that the true object of treatment is never by choice merely palliative,but curative,and for curethereis needed the detectionand removalof an activecause.The revelation of the causesof insomnia is, indeed, no simple matter. Thus much, however, we may sayâ€"¿ namely, that just as the state of the brain in normal sleepimplies a quiescentcerebral circulation some whatreduced in volume, soin thosewhosenightsare habitually restlesswe shall commonly find a con dition of cerebral vascular tension. This, let it be noted, is not incompatible with general anaemia or with defective brain nutrition. There is, indeed, nothing soconduciveto local vascularcongestionas the constant exerciseof a weakened organ. Mental worry thus acts upon the jaded brain, and we need not wonder, therefore, that it â€oe¿ murdersâ€• sleep.The

Sleeplessness
Whether as appearslikely, sleeplessness is more characteristic of our own days than thoseof our predecessors, or that, in accordance with a scientific fashion,it isnowmorenoticed, wecertainlyhearof its prevalence with somewhat startling frequency.
The nostrums proposedfor thecureof thisdisorder are numerous. Many, if not most of them â€"¿ we do not for the moment speak of narcotic drugs â€"¿ are empiri cal,andarecastuponthepublicintelligence without any consciousreference to causesactually at work upon the brain and other nervoustissues.It doesnot necessarily follow that they are valueless, and we should no more think of repudiating their ordinarily legitimateexercisethan of refusingthe occasional aid of suchmedicinal agentsasmay be trusted safely to discharge the same needful function. It is to be understood, however,that we would, wherever truemeansof reliefisasclearasit isoftenimpossible.
In suchcases,however,and still more in otherswhere adequate,or evenmore than adequate, nutritionis maintained,we find a simpleand readyantidotein physical exercise. Muscular activity, in fact, may be employed to balance nervous irritation. In it we provide a means of counter exhaustion. There is a transferenceof vascular excitement, and of tension, with corresponding relief at the site first affected. Further, the same processimplies a stimulation of the general metamorphic energy and the removal from the tissuesof irritant excretableproducts. This brings us to another causeof insomnia, particularly of that which we sometimesobservein the gouty and rheumatic. It isprobably on theground of removal of suchsuperfluoussubstancesthat we mustexplain the salutary action of the traditional â€oe¿ night-capâ€• of hot water, or the boiled onion, a stimulant of the kidney, at supper. Where mental over-activity or irritation hasto do with insomnia,the influenceof changeâ€"¿ thatis,of achangein thoughtâ€"¿ shouldhavea trial. It isno doubt a blindgropingafter this remedy that inducessome to read themselves asleep. Betterin several ways is the practice introduced by the German Kant, who spent some time before he retired for the night in cuttingoff by an effort of thought each mental occupationof the previousworking hours.We might, however,multiply the stock of remedieswithout meetingall possibleneeds.The desirablecoursefor any sleepless unfortunateto adopt is obviously not to resort to sedativedrugs to allay hisdistress,but to seekthe adviceof his trusted medical attendant and its remedy in the discovery and the removal of its cause.